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-$ APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601,. Ht <br /> ES TON AVE., STOCKTON, CA <br /> r ephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. � <br /> 9Szrnty, Size P _ <br /> Job Address 4 <br /> I� <br /> Owner's Name Address one 1 <br /> Contractor <br /> Address License No. hone <br /> TYPE OF WELL/PUMP: N EW WELL ❑ �: WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL -OTHER WELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A�R ,4-'��NSTRUtrI&N iPECTk'ATIONS— <br /> . Dia. of Well Excavation Dia N,; <br /> El Domestic/ <br /> Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Domestic/Private ❑ Gravel Packf Tracy Type of Casing Specifications 1 <br /> . a i T e_bf.Grout <br /> ❑ Publ" ❑.Othei---A3 .pelta Depth of Grout Seal YP ' <br /> rox. Depth )❑,Eastern; Surface Sea] Installed by t <br /> rPigation �ApP w , ! v f:_A <br /> t,�.. _ { H.P. State Work Don <br /> RepaulWork Done ❑ TType of Pump i } <br /> f 9 Well Destruction CAS Well Diameter Sealing Material Itop 50'} <br /> I Depth._ ms's Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW IN$T,ALLATION C REPAIR/ADDITION ❑ DESTRUCTION ❑ (No.septic system'permitted.if public sewer is <br /> available within 200 feet.) <br /> i Installation will serve: Retidence_ Commercial_ FOther <br /> Number of living units: Number of bedrooms-- <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ! SEPTIC TANK ❑ i Type/Mfg Capacity No. Compartments ' <br /> } <br /> PKG. TREATMENT PLT. ❑ _ �—� Method of Disposal : <br /> Distance to nearest:' Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i , <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number C <br /> ' SUMPS L1Distance to nearest: Well Foundation—'Property Line <br /> DISPOSAL PONDS ❑ <br /> Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a <br /> rdk <br /> ' rules and regulations of the San Joaquin Local Health District. <br /> Home owner or lice ent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> r employ any on in such er as to become subjec o workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies th ollowing: "I certify hat in the r the work fo which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws f California." <br /> The appli ant at all requi i ns. dra ng on re de. Q <br /> Signed itis: o <br /> i Date: <br /> FO DEPA ENT USE ONLY () Area <br /> Application Accepted by <br /> Date 'a g <br /> Pit or Grout Inspection by <br /> Date Final'In coon by <br /> r Additional Comments: <br /> 2-&W <br /> � ❑ Stk 466-67$1 Ll Lodi 369-36'11 C1 Manteca 623-7104 ❑ Tracy 835-63$5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO // - <br /> +'EH 1344 iREV.1/a 5) <br /> EH 1428 <br />